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Lory Bright‐Long, MD, CMDMedical Director, Maria Regina Residence

Psychiatry Consultant, LISVH

Clinical Assistant Professor of Psychiatry, SUNY Stony Brook

631‐299‐3006

ObjectivesAt the conclusion of this session the participant will:

Be prepared to discuss the scope and severity of the epidemiology of dementia

Demonstrate an understanding of the complexities of the neurobehavioral aspects of dementia

Recognize the societal and regulatory pressures associated with dementia care in today’s skilled nursing homes

Be able to educate staff about general trends in non‐pharmacological treatment of dementia behaviors

Be able to offer specific guidance about treatment of distressing behaviors

PET Scan of 20-Year-Old Brain PET Scan of 80-Year-Old Brain

PET and Aging

ADEAR, 2003

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Nosology of MCI

NORMAL 

AGIN

G

AAMI

MCla

AACD

CIN

D

DEMENTIA

Cognitive Functionin

g

Lower

Higher

Nosological Categories

AAMI= Age‐associated memory  impairment,   1 SD below  young norms

MCIa= (amnestic) mild cognitive impairment, 1.5 SD below peer norms

AACD= Age‐associated cognitive decline,1 cognitive domain SD below peer

CIND= Cognitive impairment not dementia,> 1 cognitive domain (s) impaired

Moderate to Severe Memory Impairment(defined as recall of 4 or less words out of 20)

0

5

10

15

20

25

30

35

65-69 70-74 75-79 80-84 85+ all65+

MenWomen

Health and Retirement Study, Civilian/Non-institutional Population

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Impact on Baby Boomers14 million baby boomerscan expect to develop dementia, including Alzheimer’s disease

~ one in five women

~ one in seven men

~ more women than men will develop dementia because women live longer, on average

The Scope of the IssueRaising dementia numbers: Reported in 2010

(Chen, et al) at least 39.4% of NH residents had cognitive impairment, 80% with behavioral symptoms associated with dementia

2004: ADAMS reviewed representative community persons with dementia 21% AD, 5%CV, 26.8% other were prescribed antipsychotics

2007: Of 2.1 million residents, 304,983 (14%) had at least one Medicare claim for an atypical antipsychotic during the six-month period and represented 1/3 cost of care

Bhattacharjee S, et al. Psychotropic drug utilization among eldernursing home residents in the United States Psychiatric Services2010; 61:655-660.

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Bartels SJ, Horn SD, Smout RJ, et al. Agitation and depression in the frail nursing home elderly patients with dementia. Am J Geriatr Psychiatry 2003; 11:231-238.

Bartels SJ, Horn SD, Smout RJ, et al. Agitation and depression in the frail nursing home elderly patients with dementia. Am J Geriatr Psychiatry 2003; 11:231-238.

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Safely Reduce Hospital Readmissions: By March 2015, reduce the number of hospital readmissions within 30 days during a SNF stay by 15 percent.Increase Staff Stability: By March 2015, reduce turnover among nursing staff (RN, LPN/LVN, CNA) by 15 percent.Increase Customer Satisfaction: By March 2015, increase the number of customers who would recommend the facility to others up to 90 percent.Safely Reduce the Off-Label Use of Antipsychotics: By December 2012, reduce the off-label use of antipsychotic drugs by 15 percent.

Dementia Impacts What Is Important

Possessions

Volunteer Work

Pets

Laughter

Respect

Children

Pain free Religion

GardeningTravel

MarriageProperty

Job

Education

Money

Sports

Hearing

Eyesight

VacationsReading

Walking

Home

Right NOW

I believe that behavior itself is not a disease. Simply put, behavior is communication. In people whose ability to communicate with words is limited (such as patients with dementia), communication tends to be more nonverbal (i.e. behavioral). Our challenge is to figure out what they are trying to say, and if they are in distress, to identify the underlying causes and precipitants. Many of the behaviors that are commonly observed in patients with dementia and that are often labeled as difficult, challenging, or bad, such as agitation, wandering, yelling, inappropriate urination, and hitting are typically reactive, almost reflexive behaviors that occur in response to a perceived threat or other misunderstanding among patients who by the definition of their underlying illness have an impaired ability to understand. ... Jonathan M. Evans, MD, MPH, FACP,

CMDVice President, AMDA−Dedicated to Long Term Care Medicine

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THE WHERE AND WHY DEMENTIA HAPPENS…

Causes of Dementia

Morris JC. Clin Geriatr Med. 1994;10:257-276

Alzheimer’s disease60%

Vascular Dementia16%

AD with infarcts

8%

AD with Parkinson’s

disease8%Parkinson’s

disease withdementia

3%

Other dementias5%

Lewy Body Dementia10 – 20 %

Vascular Dementia

CORTICAL= Amnesia, Aphasia, 4 As Apraxia, Anomia

SUBCORTICAL= Dysmnesia, Delay, 4 Ds Dysexecutive sx,

Depletion

HIVDirect 

neurotoxicityy

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DIFFERENTIAL DIAGNOSIS FOR                          MENTAL STATUS/MOOD CHANGES

D=  DELIRIUM, Drugs, Depression

E=  Eyes, Ears, Environment

M= Metabolic (heart, lung, liver, kidneys)

E=  Endocrine (diabetes, thyroid)

N= Neurological, Normal Pressure 

Hydrocephalus, Nutritional

T= Tumor, Trauma

I=  Infection (CNS, general), Impaction

A= Anemia, ALCOHOL 

Worsening ofDementia

Risk Factors

VulnerabilityAge

Preexisting cognitive impairmentPrevious delirium

CNS disorder, Basal ganglia disorder Increased blood brain permeability

EnvironmentalSocial isolationVisual deficits

Hearing deficitsImmobility

Novel environsStress

MedicalPAIN

Severity of comorbidityBurns

HIV/AIDSOrgan insufficiency

InfectionHypoxemia

FractureHypo/Hyperthermia

MetabolicDehydrationLow albumin

DrugPolypharmacyDrug/alcoholPsychoactive

Anticholinergics

SurgicalPerioperative

Type of surgeryEmergency ProcedureDuration of surgery

00

3030

MM

SE

MM

SE

Repetitive / Forgetful

Loss of ADLs

Behavioral Problems

NH Placement

Death

YearsGauthier, 1996

The Progression of Alzheimer’s Disease

Caregiver Distress

Difficulty with Complex Tasks

Early/ Mild Moderate Severe

No Treatment

AChI

AChI + Namenda

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Positron Emission Tomography (PET) Alzheimer’s Disease Progression vs. Normal Brains

G. Small, UCLA School of Medicine.

NormalEarly 

Alzheimer’sLate 

Alzheimer’s Child

Principles of Dementia Care   Something can be done at all stages!

Excess disability is multi‐determined 

Residual strengths matter

Presume the person has feelings and needs, even if not verbalized

Think of yourself and loved one as a unit 

Continuing education and support is crucial

Sometimes behaviors require medication

Ensure safety, dignity, and quality of life

The Who, What, Where, When, Why, and How of Behaviors

Who has behavioral changes ?

What is a behavior?

Where to these behaviors happen ?

When do behaviors happen?

Why do behaviors happen ?

How do we handle behaviors ?

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PEAK FREQUENCY OFBEHAVIORAL SYMPTOMS AS AD PROGRESSES

Jost BC, Grossberg GT. J Am Geriatr Soc. 1996;44:1078‐1081

Months Before/After Diagnosis

‐40        ‐30       ‐20         ‐10          0           10         20         30  

Frequency (% of Patients) 100

80

60

40

20

0

Agitation

DiurnalRhythm

Irritability

WanderingAggression

HallucinationsMoodChange

SociallyUnacc.

Delusions

Sexually InappropriateAccusatory

SuicidalIdeation

Paranoia

Depression

Anxiety

SocialWithdrawal

Incidence of Behaviors Apathy (72%)

Agitation (60%)

Anxiety (45%)

Irritability (42%)

Motor restlessness (38%)

Disinhibition (36%)

Sleep disturbance (24%)

Depression (23%)

Delusions (22%)

Hallucinations (10%)

The Stages of Alzheimer’s Disease

Mild Moderate SevereMild Moderate Severe

Memory lossLanguage

problemsMood and

personalitychanges

Diminishedjudgment

Withdrawal from activities

Require assistance with all IADLs*

Unable to learn or recall new info

Long-term memoryaffected

Behavioral,personality changes

Wandering, paranoia,aggression,

Placement initiated

Loss of ADL’sIncontinenceDysphagiaMuteMotor

disturbancesUnstable gait BedriddenPlacement

common

Stage

Symptoms

*IADLs = Instumental Activities of Daily Life phone,banking,shopping)

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THE A–B‐C‐Ds of Behavior Assessment

A

The antecedent – What happens before the behavior

B

The Behavior – Describe

C

The Consequence – What happens after the behavior. Are there rewards or negative results?

D

THE DANGEROUSNESS‐ FOR BOTH THE INDIVIDUAL AND THE CAREGIVER

Describe Specific Target Symptoms

Physical1,2 Verbal1,2 PassiveHitting Threats Silence

Pacing Accusations Poor po intakeKicking Name-calling WithdrawalBiting Obscenities Dead weightPushing Complaining ListlessSpitting Attention-seeking Hand wringingScratching Screaming Blank Stare

1. Cohen-Mansfield J. Int Psychogeriatr. 1996(Summer);8(2):233-245. (Review)2. Tariot PN, Mack JL, Patterson MB, et al. Am J Psychiatry. 1995(Sept);152(9):1349-1357

ANGER:  A feeling of displeasure resulting from injury,             mistreatment, opposition and usually showing itself in a desire to fight back at the supposedcause of this feeling 

When are you more likely to feel angry?

confronted with something you don’t understand ?

slighted ?

someone does not listen to you ?

something unjust occurs ?

unfairly accused ?

you don’t get your way ?

you’re tired ?

impatient ?

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AGITATION: Physical or vocal behavior that is distressing to the individual or those around the person and not in response to a specific need.

Despite the physical or vocal behavior, it is NOT agitation if there is a physical or emotional unmet need

A catch‐all term that has little meaning

Learn to describe the behavior specifically 

Learn to quickly assess the situation for causes of distress

Behavioral Interventions

Behavioral contracting

Behavioral modification and token systems

Brief directive psychotherapy

Desensitization

Distraction

Family therapy

Group therapy 

Hypnosis

Milieu and attitude therapy 

Paradoxical therapy

Reframing the problem

Relaxation training 

Reminiscence and milestoning

Time out

Validation

Restrictive and aversive therapies (Only in special units)

GENERAL TIPS IN ADDRESSING BEHAVIORS:

Modify the setting to “fit” demented resident’s needs, not vise versa.

Socialization to decrease loneliness, increase self esteem and well being.

Integrating with community and familiar activities, especially intergenerational.

When there is aggression, investigate roles of caregiver

Offer a variety of choices but limit decision‐making.

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Offer a variety of choices but limit decision‐making..

Listen to what the person is trying to say (Validation)

I want to go home: “I’m lonely”, “I’m lost”, “Nothing looks familiar”

I have to get to work: “I don’t feel important now”, “I need something to do”, 

Where is my mother?: “I have to be taken care of…” 

MORE GENERAL TIPS IN ADDRESSING BEHAVIORS:

RESISTIVENESS:

CalmnessMatter-of-factExplain each procedure simplyPrivacy and modesty are keyOffer single steps Offer opportunity to participateTalk during process.

SUSPICIOUSNESS:

BE CALM Please don’t take it personally Avoid arguments.

Do not whisper or discuss things in front of the person as if they are not there

Help look for missing items Know hiding places Keep duplicates Reduce clutter Always check the waste baskets and

pockets

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Aggression severe restlessness: BE CALM

Try music

Find constructive tasks

Use food and other pleasant distractions

HAVE AN EMERGENCY PLAN

Wandering:Identification

Label rooms and objects

Use pictures

Monitoring

Mental

Learning

Creativity

Flexibility

Focus

Examples of VALIDATION Rose has to get home to feed her children lunch.

Bud has to catch a bus into the City.

All Irene can do is rock

Herb pounds on the desk or the chair table or anything he can get his hands on

Helen seems angry (or sad, or frightened) most of the time

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Physical

Exercise

Diet

Sleep

Share symptoms with your doctor

Avoid medicating oneself

Increases strength and vigor, therefore, increase opportunities for more interaction.

Decreases depression, therefore, increases self esteem and well being.

Fatigues elders, therefore, decreases wandering, agitation, pestering.

Keeps person active in day, therefore, resynchronizes schedule for night‐time sleep.

Fostering reminiscence and relationships.

Dementia – TreatmentNon‐pharmacologic alternatives to antipsychotics: Evidence grades from A (strongest) to D (weakest)

RCT: randomized controlled trial

Treatment Evidence/Results

Caregiver psycho education/support Several positive RCT’s (evidence grade A)

Music Therapy 6 RCT’s positive in the short term (evidence grade B)

Cognitive stimulation therapy Three‐quarters of RCT’s showed some benefit (evidence grade B)

Snoezelen therapy (controlled multisensory stimulation)

3 RCT’s with positive short‐term benefits (evidence grade B)

Behavioral management therapies (by professionals)

Largest RCT’s with some benefits (evidence grade B)

Staff training/education Several positive studies of fail‐to‐goodmethodological quality (evidence Grade B)

Reality orientation therapy Best RCT showed no benefit (evidence grade D)

Teaching caregivers behavioral management techniques

Overall inconsistent results (evidence Grade D)

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Dementia – TreatmentNon‐pharmacologic alternatives to antipsychotics:

Evidence grades from A (strongest) to D (weakest)

RCT: randomized controlled trial

Treatment Evidence/Results

Simulated presence therapy Only 1 RCT which was negative (evidence grade D)

Validation therapy 1 year RCT with mixed results (evidence grade D)

Reminiscence therapy A few small studies with mixed methodologies (evidence grade D)

Therapeutic activity programs (such as exercises, puzzle play)

Varied methods and inconsistent results (evidence grade D)

Physical environment stimulation (such as altered visual stimuli, mirrors, signs)

Generally poor methodology and inconsistent results; best results with obscuring exits to decrease exit‐seeking (evidence grade D)

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Emotional

Getting and giving love

Joy

Awareness of one’s emotions

Control over reaction to emotions

THE BILL OF RIGHTS1. Know one’s diagnosis2. Have appropriate/ongoing medical care3. Have the opportunity to be productive in               

work and play as long as possible4. To be treated like an adult, not a child5. To have expressed feelings taken seriously6. To be free of unnecessary medications7. To be in a safe, structured, predictable 

environment8. To have meaningful activities available9. To have the opportunity to be outdoors10. To have physical contact11. To have those around me know of my 

background, culture, and values12. To be cared for by people who are trained          

in dementia care

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Spiritual

Connection with something bigger than self

Values

May or may not be about organized religion

Symptoms and Syndromes Overlap

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Neurotransmitter Deficiencies in AD

Nucleus basalisof Meynert

(acetylcholine)

Raphe nuclei(serotonin)

Locus ceruleus(norepinephrine)

Examples of Use of Metaphors “Depressive”                                               

Irritable, pessimistic, sad, weepy, socially withdrawn,vegetative features 

A place for antidepressant trial

“Psychotic”                                                         Angry when approached, overly suspicious,                    fragmented speech/thinking

A place for possible antipsychotic medications

“Manic” Euphoric, irritable, accelerated, hypersexual, silly 

A place for mood stabilizers

Medications Available

Cognitive enhancers

Cholinergic medications

NMDA receptor blockers

Antidepressants

Mood Stabilizers (AED)

Antipsychotics

Anxiolytics

Hypnotics

Barbituates / Miscellaneous

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Maher, et al. Efficacy and comparativeEffectiveness of atypical antipsychotic medications for off-label uses in adults

Dementia – TreatmentPharmacologic alternatives to antipsychotics:

Treatment Evidence/Results

Selective serotonin reuptake inhibitors

2 positive studies with citalopram (more effective than placebo for agitation in 1 trial and equivalent to risperidone for psychosis and agitation with greater tolerability in the other); 2 negative trials with sertraline

Other antidepressants 1 study showed trazodone was equivalent to haloperidol for agitation, with greater tolerability; another found trazodone was no different from placebo; other agents have only case reports or open label trials

Anticonvulsants 3 trials showed divalproex was equivalent to haloperidol for agitation, with greater tolerability problems in both; other agents tried only in case reports or open‐label trials

Benzodiazepines/ anxiolytics

3 trials showed oxazepam, alprazolam, diphenhydramine, and buspirone were equivalent to haloperidol in effects on agitation, but none used a placebo control; trials had problematic methodologies and indicated cognitive worsening with some agents (especially diphenhydramine)

Cognitive enhancers Some evidence of modest benefit in mostly post‐hoc data analyses in trials designed to assess cognitive variables and often among participants with overall mild psychiatric symptoms; prospective studies of rivastigmine and donepezil specifically designed to assess neuropsychiatric symptoms have found no difference compared with placebo

Miscellaneous drugs Failed trial of transdermal estrogen in men; small study showed propranolol (average dose 106 mg/d) more effective than placebo 53

SIDE EFFECTS AS A DECISION-MAKING TOOL

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